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1.  Measures of satisfaction with care during labour and birth: a comparative review 
Background
Satisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth.
Methods
A review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported.
Results
Nine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R).
Conclusions
Despite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.
doi:10.1186/1471-2393-13-108
PMCID: PMC3659073  PMID: 23656701
Patient satisfaction; Labour; Birth; Questionnaire; Measurement
2.  Policies for care during the third stage of labour: a survey of maternity units in Syria 
Background
Care for women during the third stage aims to reduce the risk of major haemorrhage, but is very variable. The current World Health Organisation (WHO) recommendation is that care should include administration of a uterotonic (oxytocin, if it is available) soon after birth of the baby, delayed cord clamping, and delivery of the placenta by controlled cord traction.
Methods
To ascertain care policies used during the third stage of labour in maternity units in Syria, we conducted a survey of 69 maternity units in obstetric and general public hospitals. A brief questionnaire was administered by face to face interview or telephone with senior obstetricians and midwives. Outcome measures were the use of prophylactic uterotonic drugs, timing of cord clamping, use of controlled cord traction, and treatment for postpartum haemorrhage. Obstetricians were asked about both vaginal and caesarean births, midwives only about vaginal births.
Results
Responses were obtained for 66 (96%) hospitals: a midwife and an obstetrician were interviewed in 40; an obstetrician only in 20; a midwife only in 6. Responses were similar, although midwives were more likely to report that the umbilical cord was clamped after 1-3 minutes or after cessation of pulsation (2/40 obstetricians and 9/40 midwives). Responses have therefore been combined.
One hospital reported never using a prophylactic uterotonic drug. The uterotonic was Syntometrine® (oxytocin and ergometrine) in two thirds of hospitals; given after delivery of the placenta in 60 (91%) for vaginal births, and in 47 (78%) for caesarean births. Cord clamping was within 20 seconds at 42 hospitals 64%) for vaginal births and 45 (75%) for caesarean births. Controlled cord traction was never used in a quarter (17/66) of hospitals for vaginal births and a half (32/60) for caesarean births.
68% of respondents (45/66) thought there was a need for more randomised trials of interventions during the third stage of labour.
Conclusion
Most maternity units report using Syntometrine®, usually given after delivery of the placenta, clamping the cord within 20 seconds, and using controlled cord traction.
doi:10.1186/1471-2393-10-32
PMCID: PMC2903494  PMID: 20569439
3.  Care during the third stage of labour: A postal survey of UK midwives and obstetricians 
Background
There are two approaches to care during the third stage of labour: Active management includes three components: administration of a prophylactic uterotonic drug, cord clamping and controlled cord traction. For physiological care, intervention occurs only if there is clinical need. Evidence to guide care during the third stage is limited and there is variation in recommendations which may contribute to differences in practice. This paper describes current UK practice during the third stage of labour.
Methods
A postal survey of 2230 fellows and members of the Royal College of Obstetricians and Gynaecologists (RCOG) and 2400 members of the Royal College of Midwives was undertaken. Respondents were asked about care during the third stage of labour, for vaginal and caesarean births and their views on the need for more evidence to guide care in the third stage. The data were analysed in Excel and presented as descriptive statistics.
Results
1189 (53%) fellows and members of the RCOG and 1702 (71%) midwives responded, of whom 926 (78%) and 1297 (76%) respectively had conducted or supervised births in the last year. 93% (863/926) of obstetricians and 73% (942/1297) of midwives report 'always or usually' using active management. 66% (611/926) of obstetricians and 33% (430/1297) of midwives give the uterotonic drug with delivery of the anterior shoulder; this was intramuscular Syntometrine® for 79% (728/926) and 86% (1118/1293) respectively. For term births, 74% (682/926) of obstetricians and 41% (526/1297) of midwives clamp the cord within 20 seconds, as do 57% (523/926) and 55% (707/1297) for preterm births. Controlled cord traction was used by 94% of both obstetricians and midwives. For caesarean births, intravenous oxytocin was the uterotonic used by 90% (837/926) of obstetricians; 79% (726/926) clamp the cord within 20 seconds for term births as do 63% (576/926) for preterm births.
Physiological management was used 'always or usually' by 2% (21/926) of obstetricians and 9% (121/1297) of midwives. 81% (747/926) of obstetricians and 89% (1151/1297) of midwives thought more evidence from randomised trials was needed; the most popular question was when is best to clamp the cord.
Conclusions
Active management of the third stage of labour is widely used by both obstetricians and midwives in the UK. Syntometrine® is usually used for vaginal births and oxytocin for caesarean births; when this is given and when the cord is clamped varies.
doi:10.1186/1471-2393-10-23
PMCID: PMC2885994  PMID: 20492659
4.  Care during the third stage of labour: obstetricians views and practice in an Albanian maternity hospital 
Background
Relatively little is known about current practice during the third stage of labour in low and middle income countries. We conducted a survey of attitudes and an audit of practice in a large maternity hospital in Albania.
Methods
Survey of 35 obstetricians and audit of practice during the third stage was conducted in July 2008 at a tertiary referral hospital in Tirana. The survey questionnaire was self completed. Responses were anonymous. For the audit, information collected included time of administration of the uterotonic drug, gestation at birth, position of the baby before cord clamping, cord traction, and need for resuscitation.
Results
77% (27/35) of obstetricians completed the questionnaire, of whom 78% (21/27) reported always or usually using active management, and 22% (6/27) always or usually using physiological care. When using active management: 56% (15/27) gave the uterotonic after cord clamping; intravenous oxytocin was almost always the drug used; and 71% (19/27) clamped the cord within one minute. For physiological care: 42% (8/19) clamped the cord within 20 seconds, and 96% (18/19) within one minute. 93% would randomise women to a trial of early versus late cord clamping.
Practice was observed for 156 consecutive births, of which 26% (42/156) were by caesarean section. A prophylactic uterotonic was used for 87% (137/156): this was given after cord clamping for 55% (75/137), although timing of administration was not recorded for 21% (29/137). For 85% of births (132/156) cord clamping was within 20 seconds, and for all babies it was within 50 seconds. Controlled cord traction was used for 49% (76/156) of births.
Conclusions
Most obstetricians reported always or usually using active management for the third stage of labour. For timing and choice of the uterotonic drug, reported practice was similar to actual practice. Although some obstetricians reported they waited longer than one minute before clamping the cord, this was not observed in practice. Controlled cord traction was used for half the births.
doi:10.1186/1471-2393-10-4
PMCID: PMC2824636  PMID: 20102601
5.  Magpie Trial in the UK: methods and additional data for women and children at 2 years following pregnancy complicated by pre-eclampsia 
Background
The Magpie Trial, a randomised trial comparing magnesium sulphate with placebo for women with pre-eclampsia. This paper describes methods used for follow up in the UK, and presents additional data collected.
Methods
In the UK 774 women and their 827 children were included; excluded were women discharged without a surviving child and families who opted out. General practitioners were sent a questionnaire when the child was around 18 months old. When the child was two years, or older, questionnaires asking about the health of the women and children were posted to families. A sample of families was offered a home visit, during which the child was assessed using the Bayley Scales of Infant Development.
Results
Of the women, 12 were lost to follow up and three died. Of the children, 12 were lost to follow up, 5 were excluded and 19 died. General practitioners returned 688/759 (91%) questionnaires, as did 619/759 (82%) women. Responses were largely comparable. 32 women had serious morbidity potentially related to pre-eclampsia. 30% of children were reported to have been admitted to hospital. There were no clear differences between the randomised groups in the child's behaviour, women's fertility or use of health service resources.
Conclusion
Data presented here provide further reassurance about the longer term safety of magnesium sulphate when used for women with pre-eclampsia. Postal questionnaires in the UK to assess the longer term health and wellbeing of women and children recruited to trials are feasible, and can achieve a high response rate. Responses from families and general practitioners were comparable
Trial registration
Trial registration number of the Magpie Trial [ISRCTN86938761]
doi:10.1186/1471-2393-9-15
PMCID: PMC2679706  PMID: 19366459

Results 1-5 (5)